SEPSIS IN POST TRANSPLANT PATIENTS

Dr.Hina Aamir AbbasiSIUT

Case

47 yrs old male patient Renal transplant 6 months ago Presented with complain of… Fever Cough Shortness of breath Confusion Fatigue Weight loss for the last two weeks

Patient was a case of End stage renal disease secondary to glomerulonephritis and was dialysis dependant prior to renal transplant

Donor was his healthy elder brother. Post transplant 6 months were

uneventful.

Drug history

Post Transplant, patient had been on immunosuppressive drugs ;

Azathioprine Tacrolimus Prednisolone

Contd..

Patient was febrile 100F fever, H/R 104b/m, R/R 40 br/min B.P100/60 and decreased urine output and GCS 12/15

Patient admitted in Transplant ICU and put on ventilatory support as his ABG’s showed picture of severe acidosis and hypoxemia.

Diagnosis..

Sepsis or acute cellular rejection??

Graft biopsy

Renal biopsy graft was sent which showed normal cellular infiltration and no rejection…

Differential diagnosis

Disseminated tuberculousis Pneumocystitis carnii pneumonia Interstitial pneumonia Klebsiella pneumonia Cytomegalovirus infection MRSA

Haematological investigations

Hb- 11.4 TLC 2900 Platelet 145 Na 135 K 3.8 HCO3 15 Cl 111 FBS 127 Urea 54 Cr 1.40

Investigations

Blood culture Viral serology for CMV, EBV Tracheal culture and BAL Stool D/R Urine C/S Sputum AFB & C/S Xray chest CT scan chest

Xray chest

CT scan chest

Results

Patient’s x ray showed diffuse interstitial infiltrates….suggestive of atypical pneumonia …

Tracheal C/S were negative

Cultures from Broncho Alveolar Lavage were positive for Pneumocystits Carnii

Treatment

Septran DS (sulfamethoxazole/trimethoprim). 

Vancomycin Acyclovir Hydrocortisone Tacrolimus Omeprazole

Management

Chest physiotherapy Nebulisation Ventilator bundles DVT prophylaxis Stress ulcer prophylaxis Fluid management and TPN of the

patient continued as per hospital protocol

Initially patient showed improvement but after 10 days his GCS began to drop

His MRI brain was done and CSF culture sent

MRI and CSF cultures

MRI brain showed multiple abnormal and intensify areas in b/l basal ganglia brain stem with post contrast enhancement seen, like infective in nature.

CSF culture was positive for CMV

Patient had superimposed CMV infection and was given Ganciclovir for 14 days and showed improvement

He was extubated and later on shifted to ward after 45 days of admission in Transplant ICU

Case discussion

As immunosupressive agents and graft survival have improved , infectious complications have become a major obstacle to infection free survival

The net state of Immunosuppressi

on

Epidemiologicalexposures

Challenges

Identification of infection in transplant recipients is difficult , as inflamatory response are blunted by immunosupression

Fever may have no infectious etiology and in fact may be an early signs of rejection.

Even if source of infection identified then balance to be kept between transplant rejection and modification of immune supression

Antibiotics chosen carefully as many are toxic to allografts.

Post transplant sepsis risk factors

Co-morbid (DM, immunosuppression) Malnutrition Unrecognised or undertreated infections Colonisation by resistant organisms

(MRSA , Pseudomonas ,enterobacter) Prolong surgery Infected graft Multiple blood transfusion Graft injury; prolong ischemia

Data shows…

Infection affects all kidney transplant recipients, in one form or another.

Over 50 percent of transplant patients have at least one infection in the first year following transplantation.

If the patient’s graft is working well more than six months post-transplant, they donot require additional immunosuppression to combat rejection, he or she is primarily at risk for infections encountered by the general population such as pneumonias and urinary tract infections.

Etiololgy

Pneumonia Urosepsis Wound infection Cellulitus Viral…...CMV, PCP, EBV, Polyoma

virus Fungal…Mucormycosis, Aspergillus, Candida Tuberculosis

Miscellaneous causes of fever

Underlying malignancy Superimposed infections Febrile neutropenia Endocarditis Meningitis Drug induced Thromboembolic phenomenon

Incidence

bacteriatuberculosisviralfungalmeningitisendocarditis5

Underlying cause

Over immunosuppression Potent immunosuppressive agents

Approach to post transplant septic patient

Think of a wider horizon….

Empirical therapy includes ……. Broad spectrum antibiotics Antivirals Antifungals Septran (trimethoprin and sulfamethoxazole) Continue immunosuppressive drugs

General principles of management Low threshold for imaging as lack of clinical

manifestation of infection

Invasive diagnostic approach is required for culture and histology

Pancultures (sputum, stool, urine, wound,CSF ) including virology and fungal cultures

Medication level (azathioprine, cyclosporine)

Considerations

Epidemiological exposures Patient’s net state of immune Time from transplantation Type of transplantation Immune response is blunted, sign and

symptoms are altered Anticipate possible organism Early treatment Cover for the right agent

Thankyou